6th Grade Student Referral Form 2019-2020
This form is for students to request counseling services. Any information shared in this form is for the use of the school counselor and will NOT be kept in the any cumulative files.
Your last name, first name
Student's grade (number or letter only. Ex. K or 3)
Level of Urgency (Need)
Priority 1- Someone is in serous danger and I need adult help ( concerned for myself or someone else.)
Priority 2- I need to talk to someone really badly! (Today)
Priority 3- I need to see you but it's not an emergency right now!
Priority 4- FYI- For Your Information ( I want to let you know)
Which category best describes the need of your student?
Personal/Social Matters - (Conflict/Drama)
Academic Support - (Grades)
Stress/Anxiety (Due to school or any other reason)
Family Issues (move, divorce, separation, death, new sibling, other...)
Brief description of issue:
Have you spoken to an adult about this situation?
Yes- If yes, please comment briefly in following question.
Please comment briefly if you answered YES to the above question.
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